Failure to Prevent and Report Resident Abuse Due to Policy and Training Lapses
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse and neglect of residents, as evidenced by an incident involving a resident who alleged that a CNA was rough during incontinent care, pushing her left shoulder and nearly causing her to hit her head on the bed rail. Another CNA witnessed the alleged abuse but did not report it promptly to the abuse coordinator, citing discomfort and fear of repercussions as a new employee. The incident was instead relayed to another CNA during shift report, who then sent a text message to the DON and ADON, but the abuse coordinator was not notified until much later by the surveyor. The DON and ADON did not immediately notify the abuse coordinator upon receiving the allegation of abuse via text message. Both later stated they did not recall receiving or responding to the message until it was brought to their attention by the surveyor. As a result, the alleged perpetrator was allowed to continue working their shift and provide care to residents after the allegation was made. The administrator confirmed that if he had been notified in a timely manner, the CNA in question would not have worked the subsequent shift. Additionally, the facility failed to ensure that CNAs received abuse training upon hire and prior to providing care. Personnel files revealed that several CNAs did not complete abuse training until weeks or months after their hire dates. The business office manager acknowledged delays in training completion and stated there was no specific policy regarding the timing of abuse training. These failures were identified during interviews and record reviews, and the lack of timely reporting and training placed residents at risk of unreported abuse and neglect.
Removal Plan
- ADON, MDS coordinator and Administrator will conduct 100% resident rounds to determine if further allegations of abuse are alleged.
- Safe surveys will be conducted by Social Worker, Human Resources and Activity Director for all cognitive residents.
- C.N.A. A was educated on Abuse, neglect and reporting by DON.
- C.N.A. B and D were suspended and terminated.
- DON and ADON were given a final written warning stating any further failures would result in termination and were re-educated by Administrator.
- The Abuse Coordinator was educated by the Regional Director of Clinical Services on how to investigate allegations of abuse, reporting of abuse and the importance of a thorough investigation and written documentation of statements and in-services.
- In-servicing was initiated by Administrator on Abuse investigation, notification, and immediate removal of the perpetrator for the DON and ADON.
- In-service will be provided to all staff on Immediate Notification of Allegations to Facility Abuse Coordinator or designee when not in facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities by DON and ADON.
- Agency staff that work in the facility or staff on PTO or LOA will have in-servicing completed prior to working the floor by the DON/ADON.
- Abuse and Neglect training will be a part of the new hire orientation and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse and resident protection from abuse and will be completed at time of hire by HR/DON and verified by Administrator.
- Any staff member who is an alleged perpetrator for any allegation will be suspended immediately pending investigation and will be escorted out of the facility immediately by the senior staff member on duty or law enforcement and will not be allowed to return to the building until the investigation is complete.
- The police were notified of the allegation of abuse by the Administrator.